A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/minute.
Resting respiratory rate of 35 breaths/minute.
The Correct Answer is A
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While assessing the station of the presenting part is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice B rationale
Monitoring maternal blood pressure is the most important assessment following the administration of epidural anesthesia. Epidural anesthesia can cause a drop in blood pressure, which can lead to complications for both the mother and the baby.
Choice C rationale
Although assessing the variability of the fetal heart rate is important during labor, it is not the most crucial assessment following the administration of epidural anesthesia.
Choice D rationale
While assessing the level of pain sensation is important to evaluate the effectiveness of the epidural anesthesia, it is not the most crucial assessment following its administration.
Correct Answer is D
Explanation
Choice A rationale
While it’s good that the client has reduced her alcohol intake, consuming alcohol during pregnancy can cause problems for the baby throughout pregnancy, including before a woman knows she is pregnant. Therefore, praising the client for her actions and offering to discuss ways to decrease consumption even more might not be enough.
Choice B rationale
Insisting that the client stop all alcohol use and drawing a blood alcohol level at each prenatal visit could be seen as invasive and might not address the underlying issue of alcohol dependency.
Choice C rationale
Notifying child protective services of the client’s illicit drug use and probable child endangerment is not applicable in this situation as the client has not mentioned any illicit drug use.
Choice D rationale
Referring the client to an outpatient alcohol abuse program for disulfiram therapy could be the most beneficial action. Disulfiram is a drug that is used to support the treatment of chronic alcoholism by producing an acute sensitivity to alcohol.
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